Payers are systematically “right-sizing” high-level E/M claims by auto-adjusting them one level down — often before anyone reviews your documentation. The AMA has flagged this behavior, yet programs keep expanding. If your practice bills 99214 or 99215 regularly, your revenue is at risk.
Maryland just fined Cigna $80,000 and ordered a halt to automatic downcoding of E/M codes 99204-99205 and 99214-99215, ruling that insurers must formally dispute claims and request documentation rather than adjusting unilaterally. But most states haven’t drawn that line yet.
against Cigna
in just 12 states
to exit Aetna program
Which Payers Are Downcoding
Cigna: R49 Policy (Effective October 1, 2025)
If claim-level criteria don’t support the billed level for 99204-99205, 99214-99215, or 99244-99245, Cigna may pay one level lower. If your appeal shows documentation supports the original level, they’ll restore payment and may remove you from the program.
Aetna: Claim & Code Review Program (Nationwide)
Aetna expanded from 12 pilot states to all commercial states except Louisiana, with Medicare Advantage expansion following. Early removal is possible if you overturn approximately 75% of downcoded claims on appeal.
Anthem BCBS: Analytic Solution (Effective February 2025)
Anthem uses an analytic tool to check whether billed E/M levels align with documentation. Selected claims may be denied, pended for records, or paid at a lower level.
12 states drive ~91% of downcoding volume: TX (17%), NJ (13%), PA (8%), VA (8%), TN (8%). If your practice is in one of these states, you are disproportionately affected.
MDM vs Time: How to Set the Right Level
E/M level selection is based on either Medical Decision Making (MDM) or total time. History and exam no longer drive level selection since the 2021 E/M revisions.
Medical Decision Making (MDM)
To hit a level by MDM, meet at least two of three elements:
- Problems addressed (number and complexity)
- Data reviewed/analyzed (tests ordered, records reviewed, independent interpretation)
- Risk of complications or morbidity/mortality of management
Time-Based E/M
When time determines the level, document total physician/QHP time on the date of encounter. You do not need to itemize each task minute-by-minute.
The 5-Step Survival Playbook
1. Tune Documentation Now
Add a level selection statement to every note: “Level set by MDM: problems + data” or “Level set by total time: 30 min.” Add specific ICD-10 codes that match complexity and risk. Link each problem to the E/M line.
2. Stand Up a Daily Remit Check
Compare paid amounts vs. contracted rates. Identify downcoded claims before appeal windows close.
3. Codify Your Appeals Process
Use a template citing AMA E/M rules. Attach the supporting note with MDM elements highlighted. For Cigna/Aetna, file reconsiderations immediately.
4. Measure Win Rate Monthly
Track appeal overturn rates by payer. If you hit ≥75% with Aetna, request program removal early.
5. Share Results with Clinicians
Show providers where appeals fail so documentation patterns improve. One provider’s weak notes can drag the whole practice into a review program.
Do / Don’t Quick Reference
| Do | Don’t |
|---|---|
| Tie level to MDM elements or total time explicitly in the note | Rely on text volume or templates to imply complexity |
| List each problem, specific tests reviewed, and risk-driving decisions | Use generic diagnoses or omit comorbidities |
| Use the most specific ICD-10 codes and link to the visit | Overuse unspecified codes that trigger edits |
| Appeal promptly with highlighted notes mapped to AMA criteria | Accept routine downgrades — it locks you into a year-long review |
Key Takeaways
- Cigna, Aetna, and Anthem all have active downcoding programs targeting E/M levels
- Maryland fined Cigna $80K — but most states haven’t acted yet
- 12 states drive 91% of downcoding volume (TX, NJ, PA, VA, TN lead)
- Add explicit level selection statements to every note (MDM or time)
- Set up daily remit checks to catch downcoded claims before appeal deadlines
- Track appeal win rates — 75%+ with Aetna triggers early program removal
- Do the work once in the chart so you don’t have to do it twice in appeals